Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sherwood Oaks Post Acute during CMS and state inspections, most recent first.
A resident with significant respiratory and neuromuscular conditions was observed using a BiPAP machine that displayed a continuous leak alarm message for an extended period without staff awareness, with the device facing the wall and its audible alarm difficult to hear. During ordered BiPAP treatment hours, the resident was instead on nasal cannula oxygen, and staff could not resolve the leak or access an operator manual, which was not available onsite despite policy requiring use of manufacturer instructions. BiPAP and oxygen orders for this resident were entered inaccurately and interpreted inconsistently by nursing staff, leading to uncertainty about required therapy times and oxygen use. In addition, two other residents had oxygen concentrators set at flow rates that did not match MD orders, and the DON could not produce required documentation of general assessments and other elements specified in the facility’s CPAP/BiPAP policy.
Surveyors found that a nebulizer mask and tubing used for PRN ipratropium-albuterol treatments for a resident with COPD exacerbation, acute and chronic respiratory failure with hypoxia, and muscular dystrophy were stored uncovered on a shelf instead of in a protective bag as required by the facility’s respiratory therapy infection prevention policy. An LVN confirmed the equipment was not properly stored per policy, and the report notes this failure had the potential to cause cross-contamination and preventable HAIs for a resident in a compromised condition.
A resident's representative was not informed of a rescheduled cardiovascular appointment, despite facility policy requiring notification of pending appointments and transportation arrangements. Documentation showed the appointment date was changed, but there was no record of notification to the responsible party, and staff confirmed this omission.
A shower room was found to be unsanitary and in disrepair, with issues such as a broken doorframe, damaged tiles, an improvised call light cord made from plastic bags, and improper storage of personal care items and sharps. These conditions were confirmed by the Maintenance Director and did not meet the facility's policy for a safe and clean environment.
Staff did not follow facility policy for labeling and storing perishable foods brought in by family or visitors. An Infection Preventionist found a plastic bag with a partially browned head of lettuce and two half-eaten sandwiches in the resident refrigerator, all unlabeled and undated. The Infection Preventionist confirmed these items should have been labeled with the resident's name and date, and could not determine how long the items had been stored.
The facility did not display the required State Survey Agency contact information and a statement about residents' rights to file complaints. A resident with moderate cognitive impairment was unaware of their rights due to this oversight. Interviews with staff, including a CNA and the DON, confirmed the absence of postings, and the Administrator acknowledged the failure in the facility's review process.
A facility failed to report a resident-to-resident abuse allegation within the required timeframe. An incident occurred where a resident reported being bumped by another resident, leading to police involvement. Despite the facility's policy requiring immediate reporting, the State Agency was not notified until several days later. Interviews revealed a lack of communication and understanding of the incident's severity among staff.
A resident was admitted with a diagnosis of psychosis and depression, but the facility failed to conduct a Level II PASRR as required. The resident's Level I PASRR did not identify any serious mental illness, and the diagnosis was missed during the admission process, particularly because it occurred over a weekend. Facility staff acknowledged the oversight in reviewing the resident's diagnosis and medications.
A resident with Alzheimer's Disease lost their custom-built hearing aids, and the facility failed to replace them in a timely manner. Instead, generic hearing aids were provided, which did not fit properly and were frequently lost. Observations confirmed the resident was without hearing aids and unable to communicate effectively. The request for replacement was still pending approval by management.
A resident in an LTC facility gave $740 to a CNA after the CNA expressed financial difficulties. The facility's policies prohibit such transactions, yet the CNA accepted the money, which was later returned in the presence of staff. This incident highlights a failure to protect the resident from financial exploitation.
A facility failed to implement a comprehensive care plan and follow physician orders for a resident with depression. The resident's care plan required administering Trazadone as ordered, but the MAR showed missing entries for monitoring depression and side effects, and the resident missed a dose. The DON and MRD acknowledged these issues but lacked documentation to confirm compliance with physician orders.
A facility failed to provide a resident's medical records in a timely manner to the resident's representative, despite a verbal and written request. The facility required a specific authorization form to be signed before releasing records, which was not aligned with their policy allowing access within 48 hours of a request. This resulted in a violation of the resident's rights.
A facility failed to implement a care plan intervention for a resident with a urinary tract infection, which required monitoring of intake and output. The Director of Nursing and Medical Records Director could not provide documentation that this intervention was carried out, despite the facility's policy requiring comprehensive, person-centered care plans with measurable objectives.
A facility failed to follow physician orders for catheter care for a resident, risking negative outcomes like urinary tract infections. The resident's Treatment Administration Record (TAR) showed missing entries for monitoring urine character and catheter placement over several months. This was confirmed by the DON and MRD during a review.
A resident did not receive a scheduled dose of Metoprolol due to a failure to follow physician orders and facility procedures. The resident's vital signs were within the parameters for administration, but the medication was withheld. The care plan required adherence to medication parameters, which was not followed, and the facility's documentation policy was not adhered to.
A facility failed to document the implementation of a fall prevention intervention for a resident with a history of falls and recent injuries. Despite having a care plan that required regular checks and assistance with toileting, there was no documentation to confirm these actions were carried out after the resident returned from the hospital. This oversight was identified during a review of the resident's medical record by the DON and Medical Records Director.
A facility failed to ensure timely monitoring and skin evaluation for a resident admitted after knee surgery. Despite orders to check for skin integrity, no assessments were documented until a deep tissue injury was found on the resident's heel two days after cast removal. The wound was later classified as stage IV.
A resident with a high risk of falling experienced an unwitnessed fall and subsequent hip fracture, but the facility failed to revise the care plan with new interventions. Despite an IDT meeting, the care plan remained unchanged until weeks later, contrary to the facility's policy.
Failure to Manage BiPAP Alarms, Oxygen Orders, and Required Respiratory Assessments
Penalty
Summary
The deficiency involves multiple failures in providing safe and appropriate respiratory care, including BiPAP management, oxygen administration, and required assessments and documentation. One resident with chronic obstructive pulmonary disease with acute exacerbation, acute and chronic respiratory failure with hypoxia, and facioscapulohumeral muscular dystrophy was observed using a BiPAP machine that displayed a continuous leak alarm message for approximately 15–20 minutes without staff awareness or intervention. The BiPAP was positioned with the front facing the wall, and although the device was designed to beep when an air leak occurred, there was no audible alarm heard by the resident or staff. Nursing staff acknowledged the leak warning on the display and that the audible alarm was difficult to hear amid facility background noise. The respiratory therapist stated that alarms are intended to inform staff when there are issues with BiPAP function and that unattended leak alarms may mean the resident is not receiving the prescribed therapeutic dose. The same resident had physician orders for BiPAP use with oxygen at 2 LPM from 1 p.m. to 5 p.m. and again from 8 p.m. to 8 a.m., and for routine oxygen at 2 LPM via nasal cannula when not on BiPAP. During an observation, the resident was found on oxygen via nasal cannula and no longer on BiPAP during the ordered BiPAP treatment time. A nurse reported that the BiPAP continued to display an air leak that could not be resolved despite multiple mask adjustments and that the supplier had been contacted for troubleshooting. When asked for the BiPAP operator manual, staff could only produce the mask manual and confirmed that the operator manual was not available in the room or onsite, despite facility policy requiring staff to review and follow the manufacturer’s instructions for CPAP/BiPAP setup and oxygen delivery. Another nurse assigned to this resident stated they did not recall the resident being on BiPAP during the afternoon and believed the resident did not need BiPAP during those hours, and also stated that the BiPAP and oxygen orders were unclear. Review of the orders showed they were entered inaccurately, with oxygen ordered from 1 p.m. to 5 p.m. instead of 1 p.m. to 6 p.m., and the DON interpreted the orders to mean the resident should be without oxygen or BiPAP between 5 p.m. and 6 p.m., despite the written order stating routine oxygen when not on BiPAP. Additional deficiencies were identified in oxygen administration and required documentation for other residents. One resident’s oxygen concentrator was observed set at 1.5 LPM, while the electronic order specified 2 LPM via nasal cannula every shift; the RN confirmed the discrepancy. Another resident’s oxygen concentrator was initially read by a nurse as 4 LPM but, upon closer inspection at eye level, was found to be set at 3.5 LPM, while the order required 4 LPM. These findings occurred in the context of professional references stating that nurses are obligated to follow physician orders unless they believe the orders are in error or would harm clients, and that orders must be assessed and clarified if potentially erroneous or harmful. Finally, when asked for documentation of general assessments prior to BiPAP procedures, the DON could not provide it, despite facility policy requiring documentation of a general assessment (including vital signs, oxygen saturation, respiratory, circulatory, and gastrointestinal status) prior to CPAP/BiPAP procedures, as well as documentation of therapy times, settings, oxygen flow, tolerance, and oxygen saturation during therapy.
Improper Storage of Nebulizer Equipment Breaches Infection Control Practices
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control practices related to the storage of respiratory therapy equipment. During observation on 4/6/26 at 2:54 p.m., a nebulizer mask and tubing used for breathing treatments for Resident 1 were found placed uncovered on a shelf in the resident’s room. Review of the resident’s Medication Review Report dated 4/6/26 showed an order for ipratropium-albuterol inhalation solution via nebulizer, 3 mg/3 mL, every two hours as needed for chest congestion, confirming that this equipment was in active use for respiratory treatment. Resident 1’s Admission Record dated 4/2/26 documented diagnoses including COPD with acute exacerbation, acute and chronic respiratory failure with hypoxia, and facioscapulohumeral muscular dystrophy, and a BIMS score of 15, indicating no significant cognitive impairment. During a concurrent observation and interview on 4/6/26 at 3:25 p.m., a Licensed Vocational Nurse acknowledged that the nebulizer tubing and mask were on the shelf, uncovered, and not properly stored according to facility policy. Review of the facility’s February 2026 respiratory therapy infection prevention policy indicated that oxygen cannulas and tubing used PRN should be kept in a plastic bag when not in use, demonstrating that the observed storage of the nebulizer equipment did not comply with the written procedure. The report states this failure had the potential to result in cross-contamination and preventable HAIs for a resident in an already compromised condition.
Failure to Notify Resident Representative of Rescheduled Medical Appointment
Penalty
Summary
The facility failed to notify the resident representative (RR) of a rescheduled medical appointment for one of two sampled residents, as required by their own policy. The RR reported that an appointment with a cardiovascular physician was changed by the provider, but the facility did not inform the RR, resulting in the RR being unable to attend the appointment. Review of the resident's progress notes showed documentation of the original and updated appointment dates, but there was no indication that the RR was notified of the change. The facility's policy on transporting residents to appointments specifies that the resident and/or responsible party will be notified of pending appointments and necessary transportation arrangements. During an interview, the Social Services Director confirmed that the RR should have been notified and acknowledged that the progress notes did not reflect such notification.
Plan Of Correction
A. What corrective action(s) will be accomplished for the patient(s) identified to have been affected by the deficient practice. It was documented in Resident 1's medical record that on 09/25/25, D.O.N. reviewed with resident's son (Michael) the findings and recommendations of the 9/24/25 vascular appointment. He did not have any issues. Resident 1 was discharged to an Independent Living Facility on 11/7/25 in stable condition and with no negative outcome. B. How other patients having the potential to be affected by the same deficient practice will be identified, and what corrective action will be taken. On 11/6/25, D.O.N. reviewed all scheduled appointments for the month of November. There are no issues on resident and/or responsible party notification of the appointment. C. What immediate measures and systemic changes will be put into place to ensure that the deficient practice does not recur. On 11/5/25 and 11/6/25, DON conducted an in-service to the licensed nurses and department managers to review the policy and procedure on "Resident's Appointments". Social Service staff will inform the resident, responsible party (if applicable), and nurses for any change in the appointment schedule. Social Service staff and Nursing will utilize the Scheduled Appointment Information form as a source of communication. D. How the facility plans to monitor its performance to ensure corrections are achieved and sustained. The plan of correction must be implemented, corrective action evaluated for its effectiveness, and it must be integrated into the quality assurance system. On 11/6/25, a QAPI Plan "Resident's Appointment Notification" was initiated by the IDT. Medical records will audit MD orders daily 5x/week to ensure that the resident and/or responsible party are notified of the appointments and documented in the record. D.O.N. and Administrator will be given a copy of the audit to ensure compliance. Findings of the audit will be discussed during the QAPI Committee meeting monthly x3 then quarterly and follow their recommendation for continued compliance. E. Dates when corrective action will be completed: November 11, 2025
Unsanitary and Unsafe Shower Room Conditions
Penalty
Summary
A shower room located in hallway four was found to be unsanitary and in disrepair during an inspection conducted with the Maintenance Director. Observations included a shower doorframe in a state of disrepair, broken wall tiles, and a call light cord that was broken and had been replaced with plastic bags instead of a proper replacement. Additionally, a bottle of lotion was stored on top of a dirty sharps container, and a used razor was found in a plastic cup placed atop a box of clean gloves. The Maintenance Director confirmed these findings during the inspection. Review of the facility's policy indicated that residents are to be provided with a safe, clean, comfortable, and homelike environment, which was not maintained in this instance.
Failure to Adhere to Food Storage and Labeling Policy for Resident Food Brought by Visitors
Penalty
Summary
Facility staff failed to follow the established policy and procedure regarding the storage and labeling of foods brought in by family and visitors for residents. During an inspection of the resident refrigerator, an Infection Preventionist observed an unlabeled and undated plastic bag containing a partially browned head of lettuce and two half-eaten sandwiches in plastic containers, also unlabeled and undated. The Infection Preventionist confirmed that these items should have been labeled with the resident's name and date, as per facility policy. When questioned, the Infection Preventionist was unable to determine how long the items had been in the refrigerator, though stated that the facility practice was to clean out the refrigerator weekly. Review of the facility's policy indicated that perishable foods must be stored in resealable containers with tightly fitting lids, labeled with the resident's name, item, and use-by date, and that staff are responsible for discarding foods showing signs of potential foodborne danger.
Failure to Post State Survey Agency Contact Information
Penalty
Summary
The facility failed to comply with federal posting requirements by not displaying the State Survey Agency contact information and a statement regarding residents' rights to file a complaint. This deficiency was identified during an observation of the facility's bulletin board, which lacked the necessary postings. The facility's policy, titled 'Federal Posting Policy,' mandates the display of such information in publicly accessible areas to inform residents, employees, and visitors of their rights under federal law. However, the absence of this information was confirmed through interviews with a resident, a CNA, the DON, and the Administrator, all of whom acknowledged the lack of required postings. A resident with moderate cognitive impairment, as indicated by a BIMS score of 12, was unaware of their right to file a complaint with the state agency due to the absence of the necessary information. The CNA and the DON also confirmed the lack of awareness and absence of postings. The Administrator admitted that the facility's monthly review process failed to ensure the required information was posted, acknowledging the oversight and expressing an expectation that all necessary data should be displayed.
Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to report a resident-to-resident abuse allegation to the State Agency within the required two-hour timeframe. On January 27, 2025, an incident occurred where Resident #39 reported that Resident #7 bumped into their wheelchair and knee. The police were called by Resident #39, but the facility did not notify the State Agency of the incident until February 5, 2025. The facility's policy mandates that any suspected abuse must be reported immediately or within 24 hours, but this protocol was not followed. Resident #39, who was admitted to the facility in 2019, has a medical history that includes depression and a traumatic brain injury. The resident reported feeling unsafe after the incident, although they were not physically hurt. Resident #7, admitted in 2021, has a history of chronic pain syndrome and bipolar disorder. Both residents have intact cognition as indicated by their BIMS scores. The facility's care plans for both residents were updated on February 4, 2025, to address the risk of emotional distress due to the disagreement. Interviews with staff revealed a lack of communication and understanding of the incident's severity. The Director of Nursing and Operations Manager were informed of a verbal disagreement but not of any physical contact. The Administrator was aware of the police presence but did not report the incident to the State Agency, relying on the police's assessment that no crime occurred. This oversight led to a delay in reporting the abuse allegation, violating the facility's policy and state regulations.
Failure to Conduct Level II PASRR for Resident with Psychosis
Penalty
Summary
The facility failed to refer a resident for a Level II Pre-Admission Screening and Resident Review (PASRR) despite the resident being admitted with a diagnosis of psychosis and depression. The facility's policy requires verification of a Level I PASRR screen for potential admissions to determine if a Level II screening is necessary. However, the resident's Level I PASRR screening did not identify any serious mental illness, and the resident was admitted without a Level II screening. The resident's medical history included unspecified psychosis and depression, and the resident was on antipsychotic and antidepressant medications. Interviews with facility staff revealed that the PASRR process was not followed correctly. The Admission Director and MDS Coordinator both acknowledged that the diagnosis of psychosis was missed during the admission process, particularly because the admission occurred over a weekend. The Director of Nursing and the Administrator confirmed that the admissions staff are responsible for reviewing new admissions to determine if a Level II screening is required, but the diagnosis of psychosis was overlooked in this case.
Failure to Replace Lost Custom-Built Hearing Aids
Penalty
Summary
The facility failed to uphold the resident's right to be treated with respect and dignity by not replacing custom-built hearing aids for a resident in a timely manner. The resident, who was admitted with Alzheimer's Disease, had custom-built hearing aids documented in their inventory of personal effects upon admission. However, these hearing aids were lost in July of the previous year, and the facility provided generic hearing aids that were ill-fitting and frequently fell off, leading to further loss. Interviews and observations revealed that the resident was without hearing aids, unable to hear or understand questions, and the request for replacement hearing aids was still pending approval by upper management. The operations manager acknowledged awareness of the situation and agreed that the resident's quality of life could be affected by the inability to hear, which impedes effective communication between the resident and staff.
Misappropriation of Resident's Money by CNA
Penalty
Summary
The facility failed to protect a resident from the misappropriation of their property, specifically involving a financial transaction with a Certified Nursing Assistant (CNA). The incident involved a resident who provided $740 to a CNA after the CNA expressed financial difficulties related to car and bill troubles. The resident and the CNA had an agreement that the money would be repaid by a certain date. This transaction was reported by the resident to the activities staff, and the CNA later returned the money to the resident in the presence of the Director of Staff Development and the Concierge. The facility's policy on abuse, neglect, exploitation, and misappropriation prevention clearly states that residents have the right to be free from such actions. Additionally, the facility's policy on gifts, gratuities, and payments prohibits employees from engaging in activities that conflict with the interests of the facility or its residents. Despite these policies, the incident occurred, indicating a failure to adhere to the established guidelines designed to protect residents from financial exploitation.
Failure to Implement Comprehensive Care Plan and Follow Physician Orders
Penalty
Summary
The facility failed to implement a comprehensive care plan and follow physician orders for a resident diagnosed with depression, who required antidepressant medication. The care plan included an intervention to administer the antidepressant medication, Trazadone, as ordered by the physician. However, during a review of the resident's medication administration record (MAR), it was found that there were missing entries for monitoring the resident for episodes of depression and adverse side effects of Trazadone on two separate occasions. Additionally, the resident did not receive the prescribed two doses of Trazadone on one occasion, receiving only one dose instead. The Director of Nursing and Medical Records Director acknowledged the missing entries and the failure to administer the medication as ordered, but could not provide additional documentation to indicate that the physician's orders were carried out on the specified dates. The facility's policy on comprehensive, person-centered care plans emphasizes the development and implementation of a care plan for each resident to maintain their highest practicable physical, mental, and psychosocial well-being. The failure to adhere to this policy and the physician's orders had the potential to negatively impact the resident.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to provide requested medical records in a timely manner to a resident's representative, violating the resident's rights. The representative of the resident made a verbal and written request for the resident's medical records on October 3, 2024. However, the facility did not fulfill this request because the representative had not signed the facility's specific authorization form titled 'Authorization Form For The Release of Health Information.' As of November 4, 2024, the requested medical records had not been provided to the resident's representative. Interviews with the Social Services Director, Director of Nursing, and Medical Records Director revealed that the facility's policy required the signing of their specific authorization form before releasing medical records, even if a verbal or written request had been made. This practice was contrary to the facility's policy and procedure titled 'Resident Rights,' which stated that residents have the right to access personal information and medical records. Additionally, the facility's 'Release of Information' policy indicated that residents could access their records within 48 hours of a written or oral request, excluding weekends and holidays. The facility's failure to adhere to these policies resulted in the deficiency.
Failure to Implement Care Plan for Monitoring Intake and Output
Penalty
Summary
The facility failed to adhere to a care plan intervention for a resident who had a urinary tract infection. The care plan, which was undated, required staff to monitor the resident's intake and output. However, during a review of the resident's care plan, the Director of Nursing and the Medical Records Director were unable to provide documentation that this intervention was carried out by the staff. The facility's policy on comprehensive, person-centered care plans, dated 2001, mandates that such plans include measurable objectives and timetables to meet the resident's needs. Despite this policy, the lack of documentation indicates that the care plan intervention was not implemented as required, potentially leading to negative outcomes for the resident.
Failure to Follow Physician Orders for Catheter Care
Penalty
Summary
The facility failed to adhere to physician orders for catheter care for one resident, which had the potential to lead to negative outcomes such as an increased risk of urinary tract infections. During a review of the Treatment Administration Record (TAR) for the resident, it was found that there were missing or blank entries on multiple dates between May and August. The physician orders required monitoring of urine character and ensuring proper placement of the catheter to prevent obstruction of urine flow every shift. However, the TAR showed that these orders were not consistently documented, as confirmed by the Director of Nursing and the Medical Records Director during the review.
Failure to Administer Metoprolol as Ordered
Penalty
Summary
The facility failed to administer Metoprolol, a medication used to treat high blood pressure, according to physician orders for one of the sampled residents. The deficiency was identified during a record review and interview with the Director of Nursing and Medical Records Director. The resident's Medication Administration Record (MAR) indicated a physician order for Metoprolol to be given twice daily, with specific parameters for withholding the medication if the systolic blood pressure was less than 110 or the heart rate was less than 60 beats per minute. On a specific date, the resident did not receive the scheduled dose of Metoprolol because the vital signs were incorrectly assessed as being outside the parameters, despite the recorded blood pressure and heart rate being within the acceptable range. The resident's care plan required adherence to the parameters for holding medication as ordered, which was not followed in this instance. The facility's policy and procedure for documentation of medication administration required documentation of reasons for withholding medication, which was not appropriately adhered to. The Director of Nursing and Medical Records Director acknowledged that the resident should have received the scheduled dose of Metoprolol based on the documented vital signs, indicating a failure in following the physician's orders and the facility's procedures.
Failure to Document Fall Prevention Intervention
Penalty
Summary
The facility failed to document the implementation of a care plan intervention for a resident who was at risk for falls. The resident, who had a history of falls and was diagnosed with an acute fracture of the right 8th and 9th ribs, head injury, and scalp laceration, was found sitting on a landing mat after falling while attempting to use the commode. The resident reported pain in the head and rib area and had a history of falling with a displaced fracture of the left clavicle, incontinence, lack of coordination, muscle weakness, and an unsteady gait. The care plan for the resident included an intervention to check the resident at least every two hours and as needed to assist with toileting. However, during a review of the resident's medical record, the Director of Nursing and Medical Records Director could not provide documentation that this intervention was carried out after the resident returned from the hospital. The facility's policies on comprehensive person-centered care plans and fall risk management emphasize the need for measurable objectives and monitoring of interventions, but the lack of documentation indicates a failure to adhere to these policies.
Failure to Monitor and Evaluate Resident's Skin Condition
Penalty
Summary
The facility failed to ensure timely monitoring and skin evaluation for a resident who was admitted following right knee surgery. The resident had a cast from the thigh to the foot, which was later replaced with a knee immobilizer. Despite physician orders to check for circulation, skin integrity, and signs of infection, the facility did not document any skin assessments until a deep tissue injury was discovered on the resident's right heel two days after the cast removal. The treatment nurse confirmed that there was no follow-up communication from the orthopedic doctor's office, and no additional orders were checked or documented. The wound consultant assessed the resident's right heel and found an unstageable injury, which was later debrided and classified as a stage IV wound. The consultant noted that such injuries could develop within a few hours due to pressure on a bony structure like the heel, especially given the resident's high-risk factors and limited mobility. The facility's policy indicated that any notable changes in the resident's condition should be documented, but this was not followed, leading to a delay in identifying and treating the pressure ulcer.
Failure to Revise Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise the care plan for a resident after a fall incident. The resident, who was admitted with diagnoses including Dementia, Anxiety, and Unsteadiness on Feet, had a history of fluctuating capacity to understand and make decisions and was assessed as having a high risk of falling. Despite an unwitnessed fall on 3/8/24 and a subsequent hip fracture discovered on 3/16/24, the care plan interventions remained unchanged from before the fall incident. This was confirmed during a review of the fall care plans dated 3/1/24 and 3/9/24, which showed similar interventions. The Nurse Supervisor acknowledged that the interventions should have been revised after the fall incident. Further interviews revealed that additional interventions were only added on 4/4/24, well after the fall incident. The Minimum Data Set (MDS) coordinator confirmed that an IDT meeting was held on 3/9/24 to address the fall, but the care plan was not updated to include new interventions. The facility's policy and procedure on care plans indicated that interventions should be derived from comprehensive assessments and input from the resident and their family, which was not adhered to in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Thousand Oaks
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Thousand Oaks Post Acute, Llc | 4.3 mi | ★★★★★ | 7 | 0 |
| Oakview Skilled Nursing | 5 mi | ★★★★★ | 0 | 0 |
| Mary Health Of The Sick Convalescent & Nursing Hos | 5.8 mi | ★★★★★ | 0 | 0 |
| Alta Healthcare Center Of Camarillo | 9.6 mi | ★★★★★ | 0 | 0 |
| Simi Healthcare Center | 11.3 mi | ★★★★★ | 2 | 0 |
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